The PEARL Study:

A Randomized Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography for Post-Cardiac

Arrest Patients without ST Elevation

Karl B. Kern, MD Professor of Medicine The Gordon A. Ewy, MD Distinguished Endowed Chair of Cardiovascular Medicine University of Arizona Co-Director, Sarver Heart Center, Tucson, Arizona

Defibrillation-What’s New?

Karl B. Kern, MD Professor of Medicine The Gordon A. Ewy, MD Distinguished Endowed Chair of Cardiovascular Medicine University of Arizona Co-Director, Sarver Heart Center, Tucson, Arizona

Conflicts of Interest Statement

Dr. Kern is a consultant and science advisory board member for Physio-Control and Zoll Inc.,

both companies manufacture defibrillators and mechanical CPR devices

2015 Defibrillation Recommendations

AHA Witnessed CA when AED present, defib ASAP Unmonitored CA when no AED present, reasonable

that CPR be initiated while AED is being retrieved Insufficient evidence to recommend artifact-filtering

algorithms during CPR Reasonable that either fixed or escalating energy

be used according to manufacturer’s instructions A single shock is reasonable (as opposed to

stacked shocks)

2015 Defibrillation Recommendations

ERC Defib should not be delayed for CPR any longer

than the time to obtain an AED or defibrillator Direct contact between the CPR provider and the

victim should avoided during defibrillation The use of 3 stacked shocks may be considered if

witnessed, monitored arrest with a defib immediately available e.g cardiac cath lab Defib shock energy levels are unchanged from

2010

ANZCOR 2016 Recommendations

Recent Defibrillation Reports

Successful Targeted AED Program in a South American mega-metropolis

Update on AED use on commercial air-carriers

Optimizing Defibrillation in Refractory VFCA

What’ On the Horizon …?

Sao Paulo, Brazil

Sao Paulo population

City limits: 12,000,000 Metro area: 21,500,000

OOH CA Response Times in Sao Paulo

Often greater than 30 min…Traffic !

The Result:

OOH VFCA survival in single digits- Probably less than 5%

Sao Paulo Metropolitan Subway System

4.5 Million passengers per day

58 subway stations

Included the blue, red, lilac, and green lines

Prospective, longitudinal, observational study

All cardiac arrests in the Sao Paulo Metro

Sept 2006 thru Nov 2012

(72% of all CA were VF)

Metro employee

*

*

*

Conclusions Implementation of a targeted AED program

in Sao Paulo metro saved lives.

Short interval between CA and Defib was key for good long-term survival.

Other major metropolitan areas in South America should consider similar programs

“Wide variability in outcome emphasizes the need for each community to ‘Know its Numbers’, then concentrate on improving by focusing on locally indentified problem areas within the Chain of Survival”

JAMA 2008;300:1462-3

O’Rourke, Quantas Airlines Circulation 1997;96:2849-2853

65 month experience: AED usage in 109 occasions 63/109 (58%) for “monitoring” 46/109 (42%) for cardiac arrest 27/46 (55%) CA in aircraft 19/46 (45%) CA in terminal

O’Rourke, Quantas Airlines Circulation 1997;96:2849-2853

Cardiac Arrest in Aircraft (n=27) 59% witnessed 11 in Asystole 10 in PEA/EMD 6 in VF (22%) 6 patients in VF upon discovery 5/6 (83%) defibrillated with AED 2/6 (33%) intact, long-term survivors 2 of 27 (7%) with good, long-term outcome IFCA

Aerosp Med Hum Perf 2016

23% 11%

(25%) (75%)

2%

0.6%

Adjusted Odd Ratio for Survival with RSR = 13.6 (5.5-33.5)

Conclusions Survival from IFCA best with RSR

The proportion of RSR is lower in IFCA suggests

delayed discovery

Flight diversions did not significantly affect resuscitation outcome

Good quality CPR and early Defib are the keys factors for IFCA survival

Refractory VF: Now What?

Refractory VF: definition “Refractory” VF Cardiac arrest patients stuck in VF after 3, 4 or 5 shocks that ALL fail to terminate VF Also called “resistant” VF Small, but not insignificant % of cardiac arrest patients (only 4-5% anecdotally)

There is also VF that is “Recurrent” VF (not truly Refractory VF) One or more shocks successfully get the patient out of VF, but they do NOT KEEP

the patient out of VF Some shocks are successful, therefore off-label approaches like DSD are not warranted Recurrent VF is much more common than refractory VF

Strategies to treat Refractory VF and Recurrent VF may or may not be the same.

Double Sequential Defibrillation (DSD)

What is it? Not an FDA (USA) approved use Using two defibrillators and two sets of pads Shocking the patient at the “same time” Two “myocardial sandwiches” instead of one

Who might get DSD? Patients stuck in refractory VF (RVF) Given after 4, 5 or 6 failed max energy shocks

One mechanistic hypothesis Likely not “doubling” energy (i.e. 360J x 2 doesn’t equal 720J) Nearly impossible to hit shock buttons simultaneously Likely delivering two max energy shocks, closely together, to cover more heart

DSD example

Possible shock timing scenarios from “shocking at the same time” Timing is not well controlled

“Sequential” Overlapping ((cancelling)

Simultaneous (highly unlikely)

A B C

15 ms 15 ms – 75ms delay

??

Double sequential defibrillation (DSD)

Single OHCA case (2014) 50 y/o AMI, cardiac arrest Persistent VF despite 5 x 200J shocks 2 defibrillators (200J biphasic each), 2 sets of pads Shocks delivered “at the same time” VF terminated (twice) Stent placed in the LAD, full recovery

Double sequential defibrillation (DSD)

29 BW Leacock, J Emerg Med 2014; 46(4):472–474

Single IHCA case (2015) 66 y/o male, inferior STEMI Developed VT/VF, standard single shocks x 15, over 72 min DSD (two 200J shocks) x 2 with conversion to NSR with ROSC Stented an 80% proximal RCA , TTM, very acidotic Did not survive to D/C

Double sequential defibrillation (DSD)

April 2015

10 OHCA cases (2015)- Wake County EMS, North Carolina All were patients in RVF Median resuscitation time 51 min Median no. standard single shocks 6.5 DSD terminated RVF in 70% of the cases 3 patients had ROSC in the field, none survived to hospital D/C

Jan/March 2015

Double sequential defibrillation (DSD)

Double sequential defibrillation vs. single shocks

June 2016

Two year OHCA retrospective analysis (2016)- San Antonio, TX 50 DSD (after 3 failed max energy shocks) vs. 229 single shocks (200J, at least 4 shocks) No difference neurologically intact survival: DSD (6%) vs. standard shock (11%) p=0.317

No difference in ROSC: DSD (28%) vs. standard shock (37%) p=0.255

DSD was no better than the standard single shock group

Refractory VF: causes Majority of non-traumatic OHCA is caused by a

cardiac causes1,3,10

A leading cardiac cause may be acute coronary occlusion/blockage (AMI)4

OHCA rhythms: VF, VT, Asystole, PEA VF that is refractory to shocks may be due to AMI Cardiologists willing to take these patients to the

cath lab are finding occlusions in the most critical coronary artery locations

Left Main and/or Proximal LAD

Refractory VF: treatment

OHCA (suspect acute coronary occlusion)

Acute Coronary Angiography

Acute Coronary PCI

PCI for Refractory VFCA: Who ?

Who is a ”viable” candidate? Arrest should probably be:

• Witnessed • Bystander CPR • Early EMS arrival and quality CPR provided • Decision for PCI during CPR made “early”, not after “all else tried and failed”

e-CPR for Refractory VFCA Key Considerations ?

Protocol to identify optimal candidates Mechanical CPR for transporting to Hospital with

ongoing resuscitation efforts • Care in ambulance ≅ Care staying at scene • Class IIb recommendation (2015)

– Choices: LUCAS™; AutoPulse™

Systemic Circulatory Support • ECMO; PCPB, Impella

CPR in Ambulance: Quality Manual:

• < 50% CPR fraction • too swallow 70% of time

Mechanical • Rate improved • CPR fraction improved • Proper depth improved Resuscitation 1997;34:235-42 Resuscitation 2008;76:185-90

CPR in Ambulance: Manual vs Mechanical

Safety first.

What can you do at the scene, that you can’t do in the ambulance, if you have mechanical CPR available ?

Accid Anal Prev 2003;35:941-8 Prehosp Emerg 2001;5:261-9

e-CPR for Refractory VFCA Key Considerations ?

Protocol to identify optimal candidates Mechanical CPR for transporting to Hospital with

ongoing resuscitation efforts Systemic Circulatory Support

• ECMO; PCPB, … Impella (?)

Resuscitation 2015;86:88-94

CHEER Trial-S. Bernard

Phase 1 trial (NCT01186614) Clinical Trial n=26 patients (11 OOH & 15 Inpt) Unsuccessful Resuscitation

Age 18-65 Cardiac etiology of CA Chest compressions begun w/i 10 min of collapse Mechanical CPR available

Intervention: Mech (AP) CPR & TH in field, ECMO in ED then PCI before ICU

Primary endpt: Survival to DC with CPC 1 or 2 Secondary endpt: ROSC, weaning ECMO, and LOS

Stub et al. Resuscitation 2015;86:88-94.

Stub et al. Resuscitation 2015;86:88-94.

JAHA 2016;5:e003732

MRC Advanced Perfusion and Reperfusion D. Yannopoulos

1. n = 18 2. OHCA with presumed cardiac etiology cardiac arrest. 3. First presenting rhythm was shockable (VF or VT). 4. Age 18 to 75 years. 5. Received at least 3 direct current (DC) shocks without sustained ROSC. 6. Received amiodarone 300 mg. 7. Body could accommodate a Lund University Cardiac Arrest 8. System (LUCAS) automated CPR device. 9. Transfer time from the scene to the CCL of <30 minutes. 10. ECMO in the CCL 11. PCI

Yannopoulos D, et al. JAHA 2016;5:e003732

Refractory OOH VFCA Studies

CHEERS1 MRC2 Sum N 11 18 29 24 Hr Surv 5/11 (45%) 10/18 (53%) 15/29 (52%) Favorable 5/5 (100%) 9/10 (90%) 14/15 Neuro among (93%) Survivors 1 Resuscitation 2015;86:88-94 2 JAHA 2016;5:e003732

Refractory OOH VFCA Studies

CHEERS *MRC’s Sum N 11 34 45 24 Hr Surv 5/11 (45%) 18/34 (53%) 23/45 (51%) Favorable 5/5 (100%) 16/18 (89%) 21/23 Neuro among (91%) Survivors * Update via personal communication 7/1/16

What’s the Future of Defib?

“Just in Time” Air Delivery of AEDs

Science Fiction?? … Maybe Not

Summary

Targeted AED Programs WORK !

CA in the Air Do it Early!

Refractory VF Look for the reason…usually ACS!

Need an AED now? …Look Up!